OB or Not OB: That’s the Ultrasound Coding Question

October 17, 2009

Question: For an ultrasound, the radiologist documented measurements of the uterus, endometrial complex, and ovaries. She noted no evidence of intrauterine pregnancy, no free fluid in the cul-de-sac, physiologic follicle formation, and positive Doppler flow in the ovaries. The patient had syncope but no confirmed pregnancy. Should I report an obstetric or nonobstetric ultrasound?

Answer: Because the patient has no confirmed pregnancy before the ultrasound, you should report a nonobstetric ultrasound.

The AMA’s CPT Assistant (October 2001) states that when a female patient presents with no confirmed pregnancy, you should report a nonobstetric ultrasound, regardless of whether the ultrasound confirms pregnancy.

On the flip side, if the patient had a confirmed pregnancy and presented for an ultrasound that might be pregnancy related, but the ultrasound does not demonstrate a pregnancy, you would report an obstetric ultrasound code.

ICD-9: Because you don’t have a confirmed diagnosis, you should report the symptom that led to the ultrasound: 780.2 (Syncope and collapse).

AUDIO TRAINING EVENT WITH CHERYL SCHAD: OIG and CMS are revving up scrutiny of ultrasound claims. Are you on the hit list?

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